TABLE K. — DURABLE MEDICAL EQUIPMENT, SUPPLIES, …

TABLE K. -- DURABLE MEDICAL EQUIPMENT, SUPPLIES, VISION AND HEARING HARDWARE NATIONWIDE- CHARGES BY HCPCS CODE v3.27 (January - December 2020) PAGE 1 of 101

HCPCS Code Modifier 1

HCPCS Code Description

A0100 A0110 A0120 A0130 A0140 A0160 A0170 A0180 A0190 A0398 A0422 A4206 A4207 A4208 A4209 A4210 A4211 A4212 A4213 A4215 A4216 A4217 A4217 A4218 A4220 A4221 A4222 A4223 A4224 A4225 A4230 A4231 A4232 A4233 A4233 A4234 A4234 A4235 A4235 A4236 A4236 A4244 A4245 A4246 A4247 A4248 A4250 A4252 A4253 A4253 A4255 A4256 A4256 A4257 A4258

Blank Blank Blank Blank Blank Blank Blank Blank Blank Blank Blank Blank Blank Blank Blank Blank Blank Blank Blank Blank Blank Blank AU Blank Blank Blank Blank Blank Blank Blank Blank Blank Blank Blank NU Blank NU Blank NU Blank NU Blank Blank Blank Blank Blank Blank Blank Blank NU Blank Blank

KL Blank Blank

NONEMERGENCY TRANSPORT TAXI NONEMERGENCY TRANSPORT BUS NONER TRANSPORT MINI-BUS NONER TRANSPORT WHEELCH VAN NONEMERGENCY TRANSPORT AIR NONER TRANSPORT CASE WORKER TRANSPORT PARKING FEES/TOLLS NONER TRANSPORT LODGNG RECIP NONER TRANSPORT MEALS RECIP ALS ROUTINE DISPOSBLE SUPPLS AMBULANCE 02 LIFE SUSTAINING 1 CC STERILE SYRINGE&NEEDLE 2 CC STERILE SYRINGE&NEEDLE 3 CC STERILE SYRINGE&NEEDLE 5+ CC STERILE SYRINGE&NEEDLE NONNEEDLE INJECTION DEVICE SUPP FOR SELF-ADM INJECTIONS NON CORING NEEDLE OR STYLET 20+ CC SYRINGE ONLY STERILE NEEDLE STERILE WATER/SALINE, 10 ML STERILE WATER/SALINE, 500 ML STERILE WATER/SALINE, 500 ML STERILE SALINE OR WATER INFUSION PUMP REFILL KIT SUPP NON-INSULIN INF CATH/WK INFUSION SUPPLIES WITH PUMP INFUSION SUPPLIES W/O PUMP SUPPLY INSULIN INF CATH/WK SUP/EXT INSULIN INF PUMP SYR INFUS INSULIN PUMP NON NEEDL INFUSION INSULIN PUMP NEEDLE SYRINGE W/NEEDLE INSULIN 3CC ALKALIN BATT FOR GLUCOSE MON ALKALIN BATT FOR GLUCOSE MON J-CELL BATT FOR GLUCOSE MON J-CELL BATT FOR GLUCOSE MON LITHIUM BATT FOR GLUCOSE MON LITHIUM BATT FOR GLUCOSE MON SILVR OXIDE BATT GLUCOSE MON SILVR OXIDE BATT GLUCOSE MON ALCOHOL OR PEROXIDE PER PINT ALCOHOL WIPES PER BOX BETADINE/PHISOHEX SOLUTION BETADINE/IODINE SWABS/WIPES CHLORHEXIDINE ANTISEPT URINE REAGENT STRIPS/TABLETS BLOOD KETONE TEST OR STRIP BLOOD GLUCOSE/REAGENT STRIPS BLOOD GLUCOSE/REAGENT STRIPS GLUCOSE MONITOR PLATFORMS CALIBRATOR SOLUTION/CHIPS CALIBRATOR SOLUTION/CHIPS REPLACE LENSSHIELD CARTRIDGE LANCET DEVICE EACH

1, 2 - See end of the table for notes regarding these fields.

Status/ Usage Indicator 2

Blank Blank Blank Blank Blank Blank Blank Blank Blank Blank Blank Blank Blank Blank Blank Blank Blank Blank Blank Blank Blank Blank Blank Blank Blank Blank Blank Blank Blank Blank Blank Blank Blank Blank Blank Blank Blank Blank Blank Blank Blank Blank Blank Blank Blank Blank Blank Blank Blank Blank Blank Blank Blank Blank Blank

Charge

GAAF Category

$27.85 $62.42 $149.31 $89.88 $1,238.42 $1.38 $268.64 $820.18 $184.35 $138.72 $136.05 $1.03 $1.03 $1.03 $1.03 $1,154.24 $57.81 $13.23 $2.06 $1.29 $1.20 $7.35 $7.35 $4.14 $86.36 $103.77 $135.72 $128.67 $103.77 $23.19 $22.82 $9.46 $5.87 $4.41 $4.41 $20.40 $20.40 $8.65 $8.65 $10.03 $10.03 $2.06 $5.88 $5.88 $7.88 $5.71 $25.24 $11.85 $65.22 $65.22 $39.38 $29.22 $29.22 $93.83 $18.32

HCPCS - Non-Drugs HCPCS - Non-Drugs HCPCS - Non-Drugs HCPCS - Non-Drugs HCPCS - Non-Drugs HCPCS - Non-Drugs HCPCS - Non-Drugs HCPCS - Non-Drugs HCPCS - Non-Drugs HCPCS - Non-Drugs HCPCS - Non-Drugs HCPCS - Non-Drugs HCPCS - Non-Drugs HCPCS - Non-Drugs HCPCS - Non-Drugs HCPCS - Non-Drugs HCPCS - Non-Drugs HCPCS - Non-Drugs HCPCS - Non-Drugs HCPCS - Non-Drugs HCPCS - Non-Drugs HCPCS - Non-Drugs HCPCS - Non-Drugs HCPCS - Non-Drugs HCPCS - Non-Drugs HCPCS - Non-Drugs HCPCS - Non-Drugs HCPCS - Non-Drugs HCPCS - Non-Drugs HCPCS - Non-Drugs HCPCS - Non-Drugs HCPCS - Non-Drugs HCPCS - Non-Drugs HCPCS - Non-Drugs HCPCS - Non-Drugs HCPCS - Non-Drugs HCPCS - Non-Drugs HCPCS - Non-Drugs HCPCS - Non-Drugs HCPCS - Non-Drugs HCPCS - Non-Drugs HCPCS - Non-Drugs HCPCS - Non-Drugs HCPCS - Non-Drugs HCPCS - Non-Drugs HCPCS - Non-Drugs HCPCS - Non-Drugs HCPCS - Non-Drugs HCPCS - Non-Drugs HCPCS - Non-Drugs HCPCS - Non-Drugs HCPCS - Non-Drugs HCPCS - Non-Drugs HCPCS - Non-Drugs HCPCS - Non-Drugs

TABLE K. -- DURABLE MEDICAL EQUIPMENT, SUPPLIES, VISION AND HEARING HARDWARE NATIONWIDE- CHARGES BY HCPCS CODE v3.27 (January - December 2020) PAGE 2 of 101

HCPCS Code Modifier 1

HCPCS Code Description

A4258 A4259 A4259 A4261 A4262 A4263 A4264 A4265 A4266 A4267 A4268 A4269 A4270 A4280 A4281 A4282 A4283 A4284 A4285 A4286 A4290 A4300 A4301 A4305 A4306 A4310 A4311 A4312 A4313 A4314 A4315 A4316 A4320 A4321 A4322 A4326 A4327 A4328 A4330 A4331 A4332 A4333 A4334 A4335 A4336 A4338 A4340 A4344 A4346 A4349 A4351 A4352 A4353 A4354 A4355

KL Blank

KL Blank Blank Blank Blank Blank Blank Blank Blank Blank Blank Blank Blank Blank Blank Blank Blank Blank Blank Blank Blank Blank Blank Blank Blank Blank Blank Blank Blank Blank Blank Blank Blank Blank Blank Blank Blank Blank Blank Blank Blank Blank Blank Blank Blank Blank Blank Blank Blank Blank Blank Blank Blank

LANCET DEVICE EACH LANCETS PER BOX LANCETS PER BOX CERVICAL CAP CONTRACEPTIVE TEMPORARY TEAR DUCT PLUG PERMANENT TEAR DUCT PLUG INTRATUBAL OCCLUSION DEVICE PARAFFIN DIAPHRAGM MALE CONDOM FEMALE CONDOM SPERMICIDE DISPOSABLE ENDOSCOPE SHEATH BRST PRSTHS ADHSV ATTCHMNT REPLACEMENT BREASTPUMP TUBE REPLACEMENT BREASTPUMP ADPT REPLACEMENT BREASTPUMP CAP REPLCMNT BREAST PUMP SHIELD REPLCMNT BREAST PUMP BOTTLE REPLCMNT BREASTPUMP LOK RING SACRAL NERVE STIM TEST LEAD CATH IMPL VASC ACCESS PORTAL IMPLANTABLE ACCESS SYST PERC DRUG DELIVERY SYSTEM >=50 ML DRUG DELIVERY SYSTEM ................
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